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Audit Risk: EHR Coding, Cloning, and Templated Notes

Physicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

9 thoughts on “Audit Risk: EHR Coding, Cloning, and Templated Notes”

Sounds like life on the Serengeti with us docs transformed into hyenas and jackals looking for the scraps that are remaining and the Pavlovian stimuli that the lion government deigns to cast down. We are more talented, educated, and deserving than a bunch of flawed-formula following bureaucrats are relegating us to.

The probable reason codes are higher is because the EMR has made it easier and faster for physicians to document everything they actually did during a visit. Before when a physician had to dictate everything it was not cost effective to take the time to document everything that was done or pay a transcriptionist to type it all.

I don’t think the government realized how much information a physician gathers from taking a history and doing a physical exam because for the above reason it was not recorded in the records in the past. The purpose for the medical record used to be for the physician to make notes to jog his/her memory of the previous visit in order to provide a continuity of care for a previously identified problem. Now, the record is used for multiple other medically non-pertinent reasons (as far as the individual patient is concerned) – justification for payment, quality measure reporting, legal documentation, meeting regulatory demands, etc.

When all of the bureaucratic bean counters got involved they decided to change the focus of the chart away from direct patient care and started playing financial games with the chart. Picky coding rules evolved including many that even the people who made the rules can’t interpret or explain in an understandable way. In response to the newly created games, the doctors simply provided ALL of the information they gathered at a visit to comply with the rules. Surprise, surprise — the government’s rules of the game backfired on them. By their rules increased documentation = increased reimbursement. Now that they don’t like the way the game is being played by the rules, the government wants to play hardball and or change the rules. “Now children – you made the rules so you need to play by the rules, You can’t go changing them in the middle of the game!” Does that sound like something you’ve told your children or grandchildren? Or how about this– “He’s just a bully, ignore him, he doesn’t know any better and he doesn’t like playing by the rules.” Or — “He’s mad because he’s just a sore loser.” Sound familiar? Grow up you government children. Enough of your games. Let us physicians just get back to taking care of patients and don’t interfere with our patient care by forcing us to play your silly games. The patients (public) are going to be the losers if you keep this up.

FACT: The best way to protect your practice is to use an EHR that does not automatically require the use of templates for documentation.
RESOLUTION: Templates are narratives of commonly encountered scenarios that are modified for each unique patient visit. The template narrative style can be converted to lists or bullets. Each line in the bulleted list can then be answered uniquely. The template is transformed into a list of statements that are uniquely answered for each patient encounter. The answers to each line develops a unique patient specific note. EMRs that are targeted for using templates may respond in a positive fashion by using standard history and physical questions in a list format that has the following added advantages:
1. There is less user fatigue by reading lists versus narratives
2. Bulleted list are better suited for complexity of documentation and billing
3. Standard lists remind the user of important points to document for care and medical necessity and help ensure a complete assessment
The list may be converted to a narrative or back to a list depending upon user preference or user intention. For example. a SOAP note may be used in a list fashion for workflow, then converted to a narrative to serve as a referral reply letter.

Q: How do you document a patient encounter but change your wording enough to document that you actually examined the patient at every visit and not just cloned the note:

RESPONSE: IMO, creating a history of present illness requires review of all relevant prior encounters: history, physical, testing and assessments and plans. Cloning of prior history narratives or physical examinations is less desirable than reviewing, verifying and adding to a chronological list of problem specific SOAP notes. I refer to this list as CSOAP. The SOAP note is a concise encapsulation of the prior visit that communicates the assessment and plan after weighing the history, physical and testing results. The time invested in a SOAP note is an investment against fraud, abuse, malpractice and promotes quality care. A chronological SOAP note that does not differ over time raises into question medical necessity or reflects the stability of the disease. Since an up to date problem list and summary of care is required, referring to a chronological list of problem specific SOAP notes in the HPI establishes the foundation for comprehensive history taking by providing past history, treatment response and list of tests and results that are weighed carefully for meaningful decision making. Cloning or carrying over problem specific SOAP notes is a desirable feature compatible with mandated up to date problem lists. The information changes in the concise chronological SOAP notes is a satisfactory method to monitor success/failure of care, complexity of the problem, extensiveness of conservative treatment, stability of the problem or exceptions to step-wise care. In addition, a chronological SOAP note that reports treatment response can be used to assess if step-wise approach or early surgical treatment is cost effective. The HPI construction can be made more informative if there is multiple inputs from the patient, physician, nurse, and PA/MA. A patient reported questionnaire at each visit, in IMO, is a key ingredient of a meaningful HPI.

IMO, for users to pay a premium for an EMR, the program must persuasively transform a patient encounter and its associated documentation into a polished work of clarity, coherence, impact, and personality. An EMR is simply a set of INSERT commands and SELECT queries of a database. The ECHOED results should be in a concise, organized and focused structure using appropriate headings, hierarchy, titles and fonts, supplemented with document and outline views to facilitate user experience, comprehension and communication. Maintaining consistent formatting allows for conversion back and forth into different formats.

Templates are used as questionnaires either in lists, tables or web pages: the form is filled by the patient, nurse, MA or by the patient at the kiosk or portal. The completed questionnaires may be scored and can be converted to a styled narrative using headings, titles, paragraphs, subtitles, strong and/or emphysis for user readability.
Please visit http://emrnotes.wordpress.com for an example.

The GUI of an EMR is the interface that the physician sees daily. The GUI is an important tool that can be developed by EMR companies to extract and present SQL data to the physician in a meaningful manner. The presentation of data is specific for each subspecialty but has some universal principles. Entering data meaningfully and presenting complex data simply is a key mission of a well constructed EMR.